Job description

Job responsibilities

IUCS Key Duties and Responsibilities:

• Provide comprehensive medical assessments, diagnoses, and treatment plans: Apply expert clinical judgement to manage patients with a wide range of acute, chronic, and complex conditions.
• Deliver care through face-to-face consultations, telephone triage, and home visits: Ensure accessible, responsive care tailored to individual patient needs across multiple settings.
• Prescribe medications and manage therapeutic interventions: Use independent prescribing authority to initiate, adjust, and monitor treatments in line with best practice.
• Identify and manage deteriorating patients requiring urgent escalation: Lead emergency decision-making and coordinate with secondary care services when necessary.
• Step up as Clinical Shift Supervisor when required: Provide clinical leadership during shifts, overseeing decision-making, risk management, and team coordination.
• Act as Daytime Lead GP to support service operations: Serve as the senior clinical point of contact, guiding complex case management and supporting colleagues.
• Manage Single Point of Access (SPOA) calls during clinical services: Triage referrals, prioritise cases, and ensure appropriate allocation to clinical pathways.
• Collaborate with multidisciplinary teams across primary, urgent, and community care: Facilitate integrated care planning and continuity for patients with complex needs.
• Lead safeguarding processes for vulnerable adults and children: Ensure timely identification, documentation, and escalation of safeguarding concerns.
• Contribute to clinical governance, audit, and service improvement initiatives: Drive quality improvement through reflective practice, peer review, and evidence-based change.
• Support and mentor clinical colleagues and trainees: Promote professional development, supervise learning, and foster a culture of clinical excellence.
• Maintain accurate, legally compliant patient record: Ensure documentation meets regulatory standards and supports continuity of care.
• Uphold infection control, health and safety, and risk management protocols: Ensure a safe clinical environment and compliance with statutory requirements.
• Communicate effectively with patients, carers, and professionals :Use clear, empathetic communication to support shared decision-making and informed consent.
• Lead and contribute to service development and strategic planning: Influence clinical pathways, workforce planning, and operational improvements to enhance patient care.

Primary Care Hubs Key Duties and Responsibilities:

Clinical Care

• Act as an expert practitioner, demonstrating clinical competence and a sound knowledge base.
• Utilise the medical model of history taking to identify diagnoses and differential diagnoses for patients presenting with unspecified presentations.
• Undertake systems based physical assessment of patients in order to diagnose and manage conditions autonomously.
• Undertake appropriate assessment, diagnosis, treatment or referral of patients booked into the minor illness clinic initiating any treatment as required and ensuring robust safety netting conversations are undertaken with each patient (or the patients carer).
• Make direct referrals to primary, secondary and social services within locally agreed pathways, guidance and protocols where appropriate.
• Ensure that patients receive high quality clinical care, delivered in a timely manner.
• Ensure complete and accurate documentation of each and every patient contact.
• Work as an independent practitioner, in order to ensure patients needs are met.
• Ensure that professional standards are maintained and within the guidance of the Department of Health and professional accountable bodies.
• Maintain clear and accurate communication with patients own practice regarding onward care.

Professional

• Adhere to own professional body requirements and always work within the scope of professional practice.
• Ensure that professional practice adheres to organisational policies, procedures and guidelines.
• Maintain a professional manner and act as a role model for others.
• Maintain confidentiality with regard to information pertaining to patients and staff.
• Ensure that the service interfaces with other partner organisations where necessary in a professional and productive manner.

Communication

• Communicate effectively with patients and families regarding complex information about their care.
• Taking a Health Coaching approach provide advice and information to patients, carers and their families where appropriate.
• Communicate effectively and work collaboratively with medical, nursing and allied health professionals, to ensure delivery of a co-ordinated service.
• Ensure accurate documentation and record keeping, in line with local policies and own professional body guidelines.
• Promote and demonstrate effective communication networks within the organisation, with partner organisations and other service providers.

Clinical Governance and Freedom to act

• Work autonomously making complex clinical decisions with limited supervision within local and national policies, being responsible for how these policies are interpreted.
• Adhere to Primary Care Hub, operating procedures and guidelines.

Service Improvement

• Contribute to quality improvement within the service through the identification and initiation of changes, which lead to better evidence-based practice and improved standards of care.
• Participate in clinical audit, identifying areas of best practice and areas for improvement.
• Contribute to the setting and monitoring of standards of care.
• Help develop the services available to the urgent care population to reflect identified needs.
• When in a senior position act as a mentor /supervisor of staff as appropriate.

Educational/Personal Development

• Contribute to the development and maintenance of an excellent learning environment.
• Adhere to professional registration requirements.
• Participate in defining your own developmental plan to maintain and develop own clinical skills and ensure own professional development.
• Ensure completion of all statutory and mandatory training.

General

• Demonstrate commitment to flexible working patterns, to meet the needs of the service and staff
• Actively contribute to the Organisations values and behaviours ensuring that relevant processes are open and transparent and encourage the confidence of staff, patients, partner organisations, the public and other agencies.
• Promote a positive organisational image.
• Promote own personal and others health, safety, and security, taking the appropriate action to report risk in accordance with policy.
• Ensure that equipment and resources are managed effectively to reduce waste and promote cost efficiency.
• Ensure the safe keeping and maintenance of equipment in accordance with policy, reporting defect or loss.
• Maintain personal development to meet the changing demands of the job, participate in an annual appraisal and appropriate training activities.
• Ensure compliance with all Kernow Health CIC statutory and mandatory training requirements, policies and protocols.

General Practice Key Duties and Responsibilities:

Main duties:

• The delivery of highly effective medical care to the entitled population
• The provision of services commensurate with the GMS contract
• Generic prescribing adhering to local and national guidance
• Effective management of long-term conditions, including care planning
• Processing of administration in a timely manner, including referrals, repeat prescription requests and other associated administrative tasks
• Undertake surgery consultations, telephone/remote consultations and electronic queries and visiting patients at home.
• On a rotational basis, undertake telephone triage and duty doctor role.
• Maintain accurate contemporaneous clinical records in conjunction with good practice, policy and guidance using read-coding where appropriate
• Work collaboratively, accepting an equal share of the practice workload
• Adhere to best practice recommended through clinical guidelines and the audit process
• Contribute to the successful implementation of continuous improvement and quality initiatives within the practice
• Accept delegated responsibility for a specific area (or areas) or the QOF
• Attend and contribute effectively to practice meetings as required
• Contribute effective to the development and maintenance of the practice including clinical governance and training
• Making professional, autonomous decisions in relating to presenting problems, whether self-referred or referred from other HCP within the organisation
• Ensure compliance with the appraisal process
• Prepare and complete the revalidation process
• Commit to self-learning and instil an ethos of continuing professional development across the practice team
• Support the partners in achieving the strategic aims of the practice, making recommendations to enhance income & reduce expenditure
• Review and always adhere to practice protocols and policies
• Encourage collaborative working, liaising with all staff regularly, always promoting a culture of continuous improvement
• Reviewing pathology/workflow for absent GP

Secondary duties:

• Participate in practice audits as requested by the audit lead
• Support the training of medical students from all clinical disciplines
• Participate in local initiatives to enhance service delivery and patient care
• Participate in the review of significant and near-miss events applying a structured approach i.e., root cause analysis (RCA)

Person Specification

Qualifications

Essential

• Registration with the General Medical Council both on the main register and on the General Medical Council (GMC) GP Register without Restrictions
• Minor Illness course or equivalent experience in the assessments and management of a wide array of minor illness presentations within your employment history
• Evidence of ongoing professional development and annual appraisal

Experience

Essential

• Clinical Assessment Level 7 or equivalent experience in undertaking whole system physical assessment
• Experience in General Practice or a role with minor illness exposure (3 Years minimum)

Disclosure and Barring Service Check

This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions.

UK Registration

Applicants must have current UK professional registration. For further information please see NHS Careers website (opens in a new window).

Employer details

Employer name

Kernow Health CIC

Address

Cudmore House

Treliske Industrial Estate

Truro

Cornwall

TR1 3LP

United Kingdom

Employer's website

https://www.kernowhealthcic.org.uk (Opens in a new tab)

Job description

Job responsibilities

My role helps deliver patient care by

The Advanced Practitioner (AP) is a frontline clinical role within Cornwalls Integrated Urgent Care Services, responsible for delivering high-quality, patient-centred care across a variety of urgent and non-urgent settings. Operating both remotely and face-to-face, the practitioner undertakes advanced clinical assessments, diagnoses, and treatments for patients presenting with acute, chronic, or undifferentiated conditions.

The APs are empowered to prescribe medications, initiate investigations, and escalate care when necessary, ensuring timely and effective interventions. In addition to clinical duties, the AP contributes to service development, quality governance, and safeguarding, while supporting integrated care pathways in collaboration with multidisciplinary teams.

They are expected to step up as Clinical Shift Supervisor when required, providing leadership and operational oversight to maintain safe and efficient service delivery.

The role also includes mentoring colleagues, promoting continuous learning, and engaging in audit and research activities to uphold evidence-based practice. This position is essential to the resilience and responsiveness of Cornwalls urgent care system.

Key Duties and Responsibilities:

• Conduct advanced clinical assessments, diagnoses, and treatment planning: Utilise enhanced clinical reasoning to manage patients with complex, undifferentiated, or multi-morbid presentations.
• Deliver care via telephone, video, face-to-face consultations, and home visits: Ensure flexible access to urgent care services, adapting approach to suit patient needs and settings.
• Prescribe medications and manage patients using clinical guidance: Apply safe prescribing practices to initiate or adjust treatment plans in line with current best practice.
• Rapidly identify and escalate deteriorating patients, initiating emergency intervention: Use clinical judgement to recognise red flags and coordinate timely escalation to emergency services.
• Step up as Clinical Shift Supervisor when required: Provide leadership and oversight during shifts, ensuring safe staffing, clinical governance, and operational continuity.
• Act as Daytime Lead Advanced Practitioner to support service coordination: Lead clinical decision-making and act as a point of escalation for complex cases during daytime operations.
• Manage Single Point of Access (SPOA) calls during clinical service: Triage incoming referrals, prioritise cases, and direct patients to appropriate care pathways efficiently.
• Collaborate with multidisciplinary teams to deliver integrated care: Work closely with GPs, nurses, social care, and other professionals to ensure joined-up patient management.
• Support safeguarding processes for vulnerable adults and children: Recognise signs of abuse or neglect and follow statutory procedures to protect patients at risk.
• Participate in clinical audits, research, and service development: Contribute to continuous improvement by evaluating outcomes and implementing evidence-based changes.
• Mentor and support colleagues, fostering a learning culture: Share expertise, supervise junior staff, and promote professional development across Maintain accurate, contemporaneous patient records: Document clinical encounters in line with legal, regulatory, and organisational standards.
• Contribute to quality governance, risk management, and infection control: Uphold safety standards and participate in initiatives to improve clinical quality and reduce risk.
• Communicate effectively with patients, carers, and professionals: Use clear, compassionate communication tailored to individual needs, including those with barriers to understanding.
• Demonstrate leadership in planning and implementing service improvements: Take initiative in developing protocols, improving workflows, and supporting workforce planning.

You will be expected to carry out any other duties that may reasonably be required in line with your main duties, as directed by your line manager.

We recognise that AI is becoming part of daily life, and you may choose to use it to help prepare your application. We welcome innovation but ask that anything you submit reflects your own abilities, experience, and voice. AI can support how you describe your skills and experience, but it should never replace your own words as we want to get to know you.

Person Specification

Qualifications

Essential

• 60 Academic Credits of relevant Level 7 Study in urgent and/or primary care and can demonstrate relevant experience and/ or accreditation to the above level.
• Can demonstrate the ability to undertake clinical system assessments and advanced decision making through relevant experience within primary and/or urgent care, or with relevant level 7 study.
• Non-Medical Independent Prescribing Accreditation

Desirable

• MSc in a relevant subject to advanced practice
• Accreditation with the Centre of Advancing Practice

Disclosure and Barring Service Check

This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions.

UK Registration

Applicants must have current UK professional registration. For further information please see NHS Careers website (opens in a new window).

Employer details

Employer name

Kernow Health CIC

Address

Cudmore House

Treliske Industrial Estate

Truro

Cornwall

TR1 3LP

United Kingdom

Employer's website

https://www.kernowhealthcic.org.uk (Opens in a new tab)

Job description

Job responsibilities

Key Responsibilities

1. Programme Management and Delivery

• Coordinate and support delivery of priorities agreed by the INT Board and Neighbourhood Leadership Team.
• Work alongside identified clinical, operational, project and workstream leads to develop and progress agreed programmes of work.
• Develop and maintain an overarching Neighbourhood Delivery Plan incorporating agreed priorities, milestones, actions, dependencies, risks and measures.
• Support project and workstream leads with appropriate programme and project management expertise.
• Coordinate activity across workstreams and partner organisations where projects have interdependencies.
• Monitor progress against agreed plans and identify delays, risks, barriers and dependencies requiring action or escalation.
• Facilitate resolution of operational barriers where these fall within agreed programme arrangements.
• Escalate matters requiring strategic, clinical, financial, workforce or organisational decisions through the appropriate governance arrangements.
• Provide clear evidence, options and recommendations to support decision-making.
• Maintain appropriate programme documentation, action logs, risk registers and assurance processes.
• Ensure agreed decisions and actions are appropriately communicated and progressed.
• Support delivery without assuming sole responsibility or accountability for projects or workstreams owned by individual organisations, clinical leads, project leads or multidisciplinary groups.

2. Operational Engagement and Service Development

• Maintain a visible presence across primary care, community services and partner organisations throughout the neighbourhood.
• Develop and maintain a detailed understanding of existing operational activity, services, pathways, workforce arrangements and service pressures.
• Engage directly with frontline clinical and non-clinical teams to understand how services operate in practice.
• Identify duplication, gaps, operational barriers and opportunities for improved integration.
• Map existing services, pathways, community assets and available resources.
• Support partners to develop and implement agreed service and pathway improvements.
• Facilitate collaboration where delivery crosses organisational or professional boundaries.
• Support development of proactive, preventative and community-based models of care.
• Ensure operational experience and feedback from staff informs neighbourhood planning and development.
• Support appropriate engagement with patients, communities and the voluntary sector when developing neighbourhood services.

3. Partnership and Relationship Management

• Develop strong and constructive relationships across primary care, community services, local authorities, VCSE organisations, acute services, mental health services and other neighbourhood partners.
• Facilitate effective multidisciplinary and multi-agency working.
• Work constructively across organisational boundaries while recognising the individual governance and accountability arrangements of partner organisations.
• Support partners to identify common priorities and opportunities for collaborative working.
• Facilitate discussions where organisations have differing operational pressures, priorities or requirements.
• Identify and support resolution of barriers to integrated working.
• Escalate issues which require strategic or organisational decisions.
• Represent the neighbourhood at appropriate programme, operational and system forums where authorised to do so.
• Maintain effective links with other neighbourhoods and system partners to support shared learning and avoid unnecessary duplication.

4. INT Board and Neighbourhood Leadership Team Support

• Support effective operation of the INT Board and Neighbourhood Leadership Team.
• Coordinate relevant meetings and ensure appropriate information is available to support discussion and decision-making.
• Prepare programme, performance, financial, risk and progress information for consideration by the Board and Leadership Team.
• Provide operational intelligence, professional advice, options and recommendations.
• Maintain appropriate records of decisions, actions and programme responsibilities.
• Monitor and support progression of agreed actions between meetings.
• Identify matters requiring escalation or formal decision.

The postholder's role is to advise, inform, coordinate and support implementation. Formal strategic decisions remain with the appropriate decision-making body.

5. Service Transformation and Pathway Development

• Support the development and implementation of integrated pathways and new models of care.
• Work with clinical and operational colleagues to understand existing pathways and identify opportunities for improvement.
• Use service activity, Population Health Management information, operational intelligence and other available evidence to inform proposals.
• Support development of proactive and preventative approaches to care.
• Facilitate service redesign activity involving multiple organisations or professional groups.
• Support appropriate use of digital technology and innovation where this contributes to agreed neighbourhood priorities.
• Explore opportunities to make effective use of existing neighbourhood resources and estates.
• Support evaluation of implemented changes and identification of further improvement opportunities.

6. Performance, Data and Reporting

• Develop and maintain appropriate mechanisms for monitoring neighbourhood activity, delivery, outcomes and impact.
• Analyse available neighbourhood data and identify relevant trends, risks, variation and opportunities.
• Develop clear and proportionate performance reporting arrangements.
• Produce regular reports for the INT Board and Neighbourhood Leadership Team covering areas including:

o programme progress;

o agreed performance measures;

o risks and issues;

o financial position;

o dependencies;

o areas requiring decision or escalation.

• Support development and maintenance of appropriate dashboards and reporting tools.
• Use Population Health Management and other available data to support service development and evaluation.
• Translate complex information into clear and accessible reports for different audiences.
• Ensure reports distinguish appropriately between factual information, analysis, recommendations and matters requiring formal decision.

7. Financial and Resource Management

• Monitor neighbourhood expenditure against agreed budgets and funding allocations.
• Maintain appropriate financial monitoring information in conjunction with relevant finance colleagues and employing organisations.
• Support financial forecasting and identification of potential financial risks.
• Provide financial information and analysis to support Board and Leadership Team decision-making.
• Support development of business cases, funding proposals and investment requests.
• Support assessment of value for money and anticipated benefits arising from neighbourhood initiatives.
• Work within agreed financial governance and delegated authority arrangements.
• Escalate proposed expenditure, commissioning decisions or resource changes requiring formal approval.

The postholder will not independently determine significant financial priorities or resource allocation for the neighbourhood.

8. Workforce and Organisational Development

• Support development of the neighbourhood workforce in accordance with priorities agreed by the INT Board and partner organisations.
• Contribute to workforce planning associated with service redesign and development of integrated teams.
• Identify workforce implications, dependencies and risks arising from proposed changes.
• Support development of new roles and ways of working where these form part of agreed neighbourhood programmes.
• Facilitate multidisciplinary and multi-agency workforce discussions.
• Work with HR, workforce and organisational development colleagues across partner organisations as appropriate.
• Support development of effective multidisciplinary team working and collaborative cultures.

The postholder will not assume employer responsibilities for staff employed by individual partner organisations unless these responsibilities are specifically delegated through an agreed management arrangement.

9. Governance, Risk and Assurance

• Support development and maintenance of proportionate programme governance arrangements.
• Maintain oversight of programme risks, issues and dependencies.
• Ensure risks are appropriately documented, reviewed and escalated.
• Support the Board and Leadership Team to maintain oversight of programme delivery.
• Work within relevant organisational policies, information governance requirements and statutory responsibilities.
• Recognise and respect the individual governance responsibilities of organisations participating within the neighbourhood.
• Identify where formal approval or organisational sign-off is required before implementation of proposed changes.

10. Continuous Improvement and Learning

• Promote a culture of continuous improvement and shared learning.
• Apply appropriate quality improvement and change management methodologies.
• Support teams to identify and test opportunities for improvement.
• Evaluate the impact of neighbourhood projects and service changes.
• Use staff, patient and community feedback to inform improvement activity.
• Share learning between projects, organisations and neighbouring INTs.
• Identify successful approaches which could be adopted more widely.
• Support the neighbourhood to learn from challenges, delays and unintended consequences as well as successful delivery.

Accountability and Decision-Making

The Strategic Manager will operate with a significant degree of professional autonomy in coordinating and supporting agreed programmes of work.

Person Specification

Qualifications

Essential

• A relevant degree-level qualification, professional/management qualification or equivalent relevant experience.

Desirable

• Formal qualification or training in project/programme management, leadership, change management or quality improvement.

Experience

Essential

• Relevant management, project, programme, service improvement or operational experience within health, social care, the public sector or another complex multi-agency environment.
• Experience of coordinating projects, services or programmes of work and supporting delivery against agreed actions and timescales.
• Experience of working collaboratively with a range of professionals, teams or organisations and building effective working relationships.

Desirable

• Experience of working within the NHS, primary care, community health services, social care or integrated care.
• Experience of working across organisational or professional boundaries within a partnership or multi-agency environment.
• Experience of service transformation, pathway redesign or implementation of new models of working.
• Experience of analysing performance or service data and developing dashboards or management reports.
• Experience of financial monitoring, budget management, business cases or funding applications.
• Experience of workforce planning or organisational development.
• Knowledge of Population Health Management, health inequalities and preventative/community-based models of care.
• Knowledge or experience of integrated neighbourhood, locality or place-based working.
• Experience of supporting senior governance groups, Boards or multidisciplinary leadership teams.

Skills and Abilities

Essential

• Strong organisational skills with the ability to manage multiple priorities, maintain oversight of actions and follow work through to completion.
• Strong written and verbal communication skills, including the ability to prepare clear reports, updates and presentations.
• Good analytical and problem-solving skills, with the ability to interpret information and identify risks, issues and potential solutions.
• Strong IT skills and confidence using Microsoft Office applications, particularly Excel, Word, PowerPoint, Outlook and Teams.
• Ability to work independently, use initiative and recognise when matters require escalation or formal decision.
• Ability to travel regularly between Callington, Gunnislake, Launceston and other locations across the neighbourhood as required.

Disclosure and Barring Service Check

This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions.

Employer details

Employer name

Kernow Health CIC

Address

Tamar Valley Health

Callington Health Centre

Haye Road

Callington

Cornwall

PL17 7AW

United Kingdom

Employer's website

https://www.kernowhealthcic.org.uk (Opens in a new tab)

Job description

Job responsibilities

The Frailty service is a planned proactive service maintaining the health and wellbeing of people living with frailty.

The post holder will work as part of a multi-disciplinary team in a patient-facing role across the East Cornwall Primary Care Network, to help improve patient outcomes, ensure better access to healthcare and support practices to manage their most vulnerable and complex patients. The role is pivotal to improving the quality of care and operational efficiencies so requires motivation and passion to deliver excellent services within general practice.

Job Purpose:

To establish a Frailty Service for East Cornwall PCN

• To identify those living with frailty within the PCN, utilising the Rockwood scoring system or other identified method.
• To support the elderly to age healthier, reducing progression of frailty and risks associated with it where possible.
• To support them to make informed choices as to their health and welfare.
• To attend and lead MDTs and work collaboratively with neighbourhood teams to support elderly and carers.
• Reduce emergency hospital admission, readmission and try to reduce care burden.
• Support early discharge planning
• To identify those likely to be within their last year of life and support them to plan for their future needs.
• Develop shared care and support plans by involving older people living with frailty, their families and carers throughout all stages of progression.
• Early identification and treatment of Delirium.

Core Responsibilities

• Develop, implement and evaluate a seamless Frailty support service across the PCN, working with community and secondary care where appropriate, and aimed at continuously improving standards of patient care and wider multi-disciplinary team working.
• Where appropriate, support the development of discharge and contingency plans with relevant professionals to arrange on-going care in residential, care home, hospital, community settings and at home;
• Periodically review, evaluate and change rehabilitation programmes to rebuild lost skills and restore confidence;
• Advise on home, and workplace environmental alterations, such as adjustments for wheelchair access, technological needs, and ergonomic support;
• Advise patients, and their families or carers, on specialist equipment and organisations that can help with daily activities;
• Assist patients to adapt to and manage their physical and mental health long-term conditions, through the teaching of coping strategies; and assess, plan, implement, and evaluate treatment plans, with an aim to increase patients productivity and self-care;
• Ensure delivery of best practice in clinical practice, caseload management, education, research, and audit, to achieve corporate PCN and local population objectives.
• Advise practices of workflow and develop SOPs for team and practices to follow and implement, particularly Personalised Care Planning, utilising best practice.

Multi-disciplinary team working (MDT)

• Ensure MDTs adhere to the Gold Standard Framework and lead MDT development and best practice across the PCN.
• Ensure the right people are involved in MDTs from the East Cornwall Neighbourhood teams and PCN teams.
• Participate in GP huddles and any other PCN/Partnership MDT and promotes effective ways of working;
• Exercise a critical understanding of personal scope of practice and to identify when a patient requires escalation or referring on to other services.
• Develop effective working relationships with the Palliative Care Team and embed new processes and ways of working if required, to avoid duplication and to enhance the patient and family experience.

Communication

The post-holder should recognise the importance of effective communication across the PCN and within the team and will strive to:

• Work with patients through a shared-decision making approach to plan realistic, outcomes-focused goals;
• Coordinate and support the provision of Personalised Care Plans; Treatment Escalation Plans; End of Life Plans;
• Undertake both verbal and non-verbal communication methods to address the needs of patients that have communication difficulties;
• Communicate effectively with other team members;
• Communicates effectively and appropriately with patients and carers complex and sensitive information regarding diagnosis, pathology and prognosis;
• Recognise peoples needs for alternative methods of communication and responds accordingly;
• Develop relationships and a collaborative working approach across the PCN supporting the integration of pathways in primary care.

Signposting

Ensure that patients are referred to the appropriate healthcare professional for the appropriate level of care within an appropriate period of time e.g. pathology results, common/minor ailments, acute conditions, long term condition reviews etc.

Service Development

Contribute to the development and implementation of new services for the PCN.

Information Management

Analyse, interpret and present data to highlight issues and risks to support decision making.

Quality Improvement

• Undertake clinical audits of in areas directed by the PCN, feedback the results and implement changes in conjunction with the practice teams.
• Demonstrates ability to identify and resolve risk management issues according to policy/protocol;
• Follows professional and organisational policies/procedures relating to performance management;
• Represents the Frailty service on relevant committees and meetings, as a lead clinician, provide input in relation to specialist issues and clinical matters as required.

Education and Training

Provide education and training to primary healthcare teams.

Care Quality Commission

Work with the general practice teams to ensure the practice is compliant with CQC standards.

Public Health

To support public health campaigns. To provide specialist knowledge on all public health programmes available to the general public.

Confidentiality

In the course of seeking treatment, patients entrust us with, or allow us to gather, sensitive information in relation to their health and other matters. They do so in confidence and have the right to expect that staff will respect their privacy and act appropriately.

In the performance of the duties outlined in this Job Description, the post-holder may have access to confidential information relating to patients and their carers, practice staff and other healthcare workers. They may also have access to information relating to the practices as a business organisation. All such information from any source is to be regarded as strictly confidential.

Information relating to patients, carers, colleagues, other healthcare workers or the business of the practice may only be divulged to authorised persons in accordance with the practice policies and procedures relating to confidentiality and the protection of personal and sensitive data.

Health and Safety

The post-holder will assist in promoting and maintaining their own and others health, safety and security as defined in the practice Health & Safety Policy, to include:

• Using personal security systems within the workplace according to practice guidelines;
• Identifying the risks involved in work activities and undertaking such activities in a way that manages those risks;
• Making effective use of training to update knowledge and skills;
• Using appropriate infection control procedures, maintaining work areas in a tidy and safe way and free from hazards;
• Reporting potential risks identified.

Equality and Diversity

The post-holder will support the equality, diversity and rights of patients, carers and colleagues, to include:

• Acting in a way that recognises the importance of peoples rights, interpreting them in a way that is consistent with practice procedures and policies, and current legislation;
• Respecting the privacy, dignity, needs and beliefs of patients, carers and colleagues.

Personal/Professional Development

The post-holder will participate in any training programme implemented by the PCN as part of this employment, such training to include:

• Participation in an annual individual performance review, including taking responsibility for maintaining a record of own personal and/or professional development.
• Taking responsibility for own development, learning and performance and demonstrating skills and activities to others who are undertaking similar work.

Quality

The post-holder will strive to maintain quality within the PCN and will:

• Alert other team members to issues of Clinical Governance issues, quality and risk; participate in any risk reviews;
• Assess own performance and take accountability for own actions, either directly or under supervision;
• Contribute to the effectiveness of the team by reflecting on own and team activities and making suggestions on ways to improve and enhance the teams performance;
• Work effectively with individuals in other agencies to meet patients needs;
• Effectively manage own time, workload and resources. He/she will also contribute to the overall team-working of the PCN putting the needs of the PCN first.
• Contribution towards practices CQC compliance rating of GOOD or above.

Person Specification

Qualifications

Essential

• Registered with the Health and Care Professional Council; or Nursing and Midwifery Council;

Desirable

• Holds a masters level qualification;
• May hold or be working towards a prescribing qualification;

Experience

Essential

• Demonstrates general skills and knowledge in core areas;
• Experienced in developing and implementing Personalised Care Plans;
• Is able to plan, manage, monitor, advise and review general frailty care programmes for patients in core areas, including disease states/ long term conditions identified by local Needs Assessment;
• Demonstrates accountability for delivering professional expertise and direct service provision;
• Able to follow legal, ethical, professional and organisational policies/procedures and codes of conduct.
• Full driving licence

Education, Training and Development

Essential

• Demonstrates self-development through continuous professional development activity;
• Demonstrates an understanding of current educational policies relevant to working areas of practice and keeps up to date with relevant clinical practice;
• Ensures appropriate clinical supervision is in place to support development;
• Enrolled into review and appraisal systems within PCN.

Collaborative Working Relationships

Essential

• Operate as a full member of the primary care team, including contributing service evaluation/improvement and research activity;
• Manage and co-ordinate the care that individual patients receive, including through liaising with other members of the MDT and with patients' carers;
• Facilitate primary care activity, with a strong emphasis on prevention and early intervention, including through the delivery of public health advice (e.g. relating to physical activity, weight management and smoking cessation);
• Contribute to the use of healthcare technologies to optimise the integration of service delivery (across teams, sectors and settings) and patients access and continuity of care;
• Contribute to the development of primary care teams, including through contributing to others' learning.

Disclosure and Barring Service Check

This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions.

UK Registration

Applicants must have current UK professional registration. For further information please see NHS Careers website (opens in a new window).

Employer details

Employer name

Kernow Health CIC

Address

Rame Group Practice

Trevol Road

Saltash

Cornwall

PL11 2TB

United Kingdom

Employer's website

https://www.kernowhealthcic.org.uk (Opens in a new tab)